HIT 101 Exam 1 5th Edition SBCC with
Complete Solutions - Sayles
*Certification - ANSWER-Given to acknowledge a specified level of knowledge,
competencies, and skills. - Tests to receive certification
CCHIM
Credentials that has specific eligibility requirements and a certification examination.
RHIT, RHIA, CCA, CCS, CCS-P, CHPS, CHDA, CDIP, CHTS
*Different Type of Data Sets - ANSWER-- Uniform Hospital Discharge Data Set
(UHDDS)
- Uniform Ambulatory Care Data Set (UACDS)
- Data Elements for Emergency Department Systems (DEEDS)
- Minimum Data Set (MDS)
- Outcomes and Assessment Information Set (OASIS)
- Essential Medical Data Set (EMDS)
*Formats of the health record - ANSWER-- Paper
- Electronic
- Hybrid
*Indices - 4 kinds - ANSWER-- Master patient index - MPI
- Disease index - (ICD - International Classification of Disease)
- Operation or procedure index (CPT - Current Procedure Terminology)
- Physician index
*Indices - ANSWER-A report or list from a database that provides help in finding data
contained in the database.
Serves as a guide or indicator to locate something within a database or other systems
storing data
*Licensure - ANSWER-Gives the person permission to practice, or the organization to
operate within a certain field of practice.
Given by an organization or governmental agency.
*Paper Health Record - ANSWER-- Source-oriented health record
ex. nurse notes grouped together, physicians notes grouped together
- Universal Chart Order - reverse chronological order
- SOAP Subjective, objective, assessment, plan - to remember what should be in the
progress note
-- SOAP came from the problem-oriented health record in the 1970's
*Primary purpose of the health record - ANSWER-- Patient care
- Management of patient care
Complete Solutions - Sayles
*Certification - ANSWER-Given to acknowledge a specified level of knowledge,
competencies, and skills. - Tests to receive certification
CCHIM
Credentials that has specific eligibility requirements and a certification examination.
RHIT, RHIA, CCA, CCS, CCS-P, CHPS, CHDA, CDIP, CHTS
*Different Type of Data Sets - ANSWER-- Uniform Hospital Discharge Data Set
(UHDDS)
- Uniform Ambulatory Care Data Set (UACDS)
- Data Elements for Emergency Department Systems (DEEDS)
- Minimum Data Set (MDS)
- Outcomes and Assessment Information Set (OASIS)
- Essential Medical Data Set (EMDS)
*Formats of the health record - ANSWER-- Paper
- Electronic
- Hybrid
*Indices - 4 kinds - ANSWER-- Master patient index - MPI
- Disease index - (ICD - International Classification of Disease)
- Operation or procedure index (CPT - Current Procedure Terminology)
- Physician index
*Indices - ANSWER-A report or list from a database that provides help in finding data
contained in the database.
Serves as a guide or indicator to locate something within a database or other systems
storing data
*Licensure - ANSWER-Gives the person permission to practice, or the organization to
operate within a certain field of practice.
Given by an organization or governmental agency.
*Paper Health Record - ANSWER-- Source-oriented health record
ex. nurse notes grouped together, physicians notes grouped together
- Universal Chart Order - reverse chronological order
- SOAP Subjective, objective, assessment, plan - to remember what should be in the
progress note
-- SOAP came from the problem-oriented health record in the 1970's
*Primary purpose of the health record - ANSWER-- Patient care
- Management of patient care
